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1 Waterloo House Inspection report 29 August 2017

Vivacare Limited

Waterloo HouseInspection report

3 Nelson GardensStokePlymouthDevonPL1 5RH

Tel: 01752567199Website: www.waterloohousecarehome.co.uk

Date of inspection visit:21 June 201722 June 2017

Date of publication:29 August 2017

Overall rating for this service Requires Improvement

Is the service safe? Requires Improvement

Is the service effective? Requires Improvement

Is the service caring? Good

Is the service responsive? Good

Is the service well-led? Inadequate

Ratings


Summary of findings

Overall summary

The inspection took place on the 21 and 22 June 2017 and was unannounced.

Waterloo House is a care home which provides accommodation and personal care for up to 20 people who have mental health needs. On the day of the inspection 17 people were living in the service (Two people were in hospital).

At the last inspection on the 12 and 25 October and 1 November 2016 we found significant concerns relating to managing people's care and risk, care planning, infection control and prevention, safeguarding people from harm, staff training and knowledge, the environment and leadership. We rated the service as inadequate overall. In line with our enforcement policy we made the decision to place conditions on the provider's registration. We told the provider they must send us monthly reports to tell us about their progress to address the concerns raised. This condition will remain in place until we are satisfied sufficient improvements have been made. We found most breaches had been met but had concerns about medicine management and the governance systems within the home.

The service has also been in Special Measures. Services are placed in special measures when they have beenrated as inadequate overall. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe.

The overall rating for this service is 'Requires improvement'. However, the service will remain in special measures. We do this when services have been rated as 'Inadequate' in any key question over two consecutive comprehensive inspections. The 'Inadequate' rating does not need to be in the same question at each of these inspections for us to place services in special measures.

At the time of the October 2016 inspection the service did not have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered person's'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the service isrun. Following the October 2016 and at the time of this inspection, a consultancy service with mental health experience was working with the provider to support improvements at Waterloo House. The provider was actively trying to recruit to a registered manager.

Following the last inspection in October 2016 we requested that the provider send us monthly reports on their progress to address areas of concern we had found. We received reports as requested and also met with Plymouth City Council to discuss the action taken to improve the quality and safety of services providedto people at Waterloo House. The quality monitoring team for Plymouth City Council told us the consultancyteam had worked closely with them and had been open and responsive when discussing the concerns found and action needed.


People and other agencies said they had seen improvements in the service during the last six months. The provider and consultancy team had spent time with staff discussing the concerns found at the last inspection and had considered what factors may have contributed to these failings. They said they had involved all the staff in these discussions and listened carefully to their views and feedback. The consultancyteam said they recognised the changes were work in progress, but felt positive progress had been made so far. Staff said improvements had been made and they felt more valued and involved in decisions about the service. Staff said they were very happy working in the home. All staff were working together as a team and keen for the service to improve.

At this inspection we found improvements had been made but further work was needed in relation to infection control, medicine management, meeting staff training needs, understanding of the Mental Capacity Act (2005) and the provider's governance systems, including updating policies to guide and direct staff. The consultancy team had prioritised areas they had considered to be of highest risk, and had addressed these within agreed timescales. They said they were aware further improvements were needed and were working closely with staff to embed some of the changes and working practice.

Medicine management processes were not always safe. We found some discrepancies with people's stock balances which could not be explained. People did not have care plans in place to guide medicine administration to ensure there was consistency across staff administering and guidance in place for when "as required" medicines might be needed. There was no a clear policy in place regarding medicine administration and there was no an audit of the medicine administration processes. The consultancy team were proactive in addressing these issues immediately undertaking an internal audit, sourcing advice and arranging in house training on best practice in this area. Further external training was being arranged for staff leading on medicines within the service.

People were protected by safer infection control practices. The home was found to be clean and well-maintained. Action had been taken to address concerns raised at the last inspection. We found the infection control policy and audit required updating to reflect best practice and staff required refresher training in thisarea. We have issued a recommendation in this area.

People were assured a better quality of service due to the new quality assurance programme. Reviews had been undertaken of the home's quality auditing systems and improvements found in the service demonstrated these were now more effective. However, there were gaps in the service's quality auditing processes at the time of the inspection. This was being addressed proactively by the consultancy service. The provider's governance framework was also not clearly evidenced to demonstrate how they ensured the service was providing high quality.

Staff told us how they always asked people for their consent as they provided care, and we observed this in practice. Not all staff had received training on the Mental Capacity Act (MCA) 2005 which would support theirunderstanding of the MCA. The MCA provides the legal framework to access people's capacity to make certain decisions, at a certain time. When people had been assessed as not having the capacity to make a decision, a best interest's decision was usually made, involving people who knew the person well and other professionals when relevant. We found recording of best interests decisions needed to be clearer for some decisions, for example if there were set house rules which might be perceived as restrictive. Some staff foundit difficult to explain the Mental Capacity Act and how this law protects people's human rights. They were being supported to understand this through everyday discussions with the consultancy team and in house training whilst formal training dates were arranged. We have issued a recommendation in this area.

People who did not have capacity and who were being deprived of their liberty had the necessary


paperwork submitted to the local authority supervisory body. People who had conditions placed upon themdue to their mental health needs were known, staff knew what these were and ensured they were met.People were supported by staff keen to develop their skills to meet their needs. Staff had received some training for example in challenging behaviour, safeguarding and first aid. Staff had also started distance learning training with an external provider. Training needs identified at the last inspection were being planned and the service was awaiting dates for Mental Capacity Act training. Staff had received a great deal of informal training and support from the consultancy service. Training in specific areas of mental health were planned for July 2017. New staff undertook a thorough induction before they started working in the home. Staff said they felt supported by their colleagues and were able to raise concerns and discuss issues about their practice. Supervision (one to ones) for staff had started to provide formal support to staff and support them through the changes being made.

Improvements had been made in the risk assessment process, and we saw all risk assessments had been reviewed and updated. Further improvements to risk assessments were planned with the introduction of a skin care and nutritional assessment tool.

People's care plans had been reviewed and care plans we looked at included clear information about people's needs and how they would be met.

People said they felt safe living in the home and would talk to staff about any worries they had. Most staff had updated safeguarding training and said they felt confident and competent to raise concerns if they felt people were at risk.

People said they felt there were enough staff to keep them safe. Staffing levels had been reviewed, and additional staff had been recruited where the need had been identified.

People's health and dietary needs were met. People had access to a range of healthcare professionals and the feedback from other agencies was positive. We were told the staff made relevant referrals and followed guidance and advice. Care records provided staff with good detail about people's healthcare needs and staff were familiar with this information. People said the food was of a good standard and they were offered choices when requested.

There was great improvement in activities and people's hobbies and interests were being considered. People were enjoying swimming and trips out to parks and garden centres. People told us they were really enjoying being out.

The atmosphere in the home throughout the two days was warm and friendly. We saw lots of caring and compassionate interactions between people and the staff supporting them. Staff told us they loved working in the home and greeted people with a smile and friendly conversation. People told us Waterloo house was their home and they were like a large family. The environment was welcoming and information was available about the activities on offer. People told us their privacy and dignity was promoted and respected.

The provider and consultancy service had written to people and relatives about the findings of the inspection and the action they would be taking to address the issues found. They had apologised to people about the failings and kept them updated of progress and improvements. This reflected the requirements of the Duty of Candour. The Duty of Candour is a legal obligation to act in an open and transparent way in relation to care and treatment and puts a responsibility on providers to promote the ethos of honesty, to learn from mistakes and admit when things have gone wrong.


We have made a recommendation about infection control and the Mental Capacity Act.

There were breaches in regulation concerning Safe Care and Treatment and Good Governance. You can see what action we told the provider to take at the back of the full version of the report.


The five questions we ask about services and what we found

We always ask the following five questions of services.

Is the service safe? Requires Improvement

Some aspects of the service required improvement to further ensure people were safe.

Aspects of people's medicine management was not always safe.

People were cared for in a clean service but infection control policies and laundry practices required reviewing and updating.

People were protected by staff who understood how to protect them from abuse and harm. People had confidence in the staff and felt safe when receiving support.

Staffing arrangements were sufficient to meet people's needs and to keep them safe.

People's risks were well managed, assessments were comprehensive, reflecting potential risk and how staff should minimise harm.

People were kept safe by improved accident and incident reporting processes.

Is the service effective? Requires Improvement

The service was not consistently effective.

People were supported by staff who were keen to develop their skills and knowledge to meet people's needs. Further training was required in some areas.

Staff always sought people's consent before providing care, although some staff did not fully understand their responsibilities under the Mental Capacity Act 2005

People were given the support they needed to make day to day decisions as well as important decisions about their lifestyle, health and well-being.

People were supported to enjoy their mealtime experience. People's specific dietary needs and particular likes and dislikes were known and understood by those preparing and providing


meals and people were offered a choice of meals if requested.

People were supported to maintain good health and prompt action was taken to address any concerns or changes in people'shealthcare needs.

Is the service caring? Good

The service was caring.

People were treated with respect and dignity and their privacy was promoted.

People received support from staff that were compassionate andcared about their work and the support they provided.

People were provided with information and their views and choices were listened to and respected.

People were able to see and contact their friends and relatives and others who mattered to them.

Is the service responsive? Good

The service was responsive to people's needs.

People's care plans were sufficiently detailed to ensure care was delivered consistently and in a way people needed and preferred.

People told us they felt their care was personalised and met theirindividual needs.

People had access to a range of activities, which reflected their interests and needs.

People were encouraged to provide feedback on the service and raise any concerns. There was a complaints policy in place but it was not clear complaints had driven improvement at the service.

Is the service well-led? Inadequate

There was no registered manager at the service. Leadership was being provided to people and staff from an external consultancy service.

There were gaps in the service's quality monitoring systems which meant the issues noted at this inspection had not been identified through the service's governance framework.


Staff felt valued but greater clarity was required about some of the management roles and responsibilities.

Prompt action had been taken to address concerns raised duringthe inspection and improvements had been made within agreed timescales.

People had been kept informed of issues relating to the service and were reassured that progress was being made to make improvements and address failings that had been found.

People's views were listened to and acted on.


Waterloo HouseDetailed findings

Background to this inspectionWe carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

At the last inspection on the12 and 25 October and 1 November 2016, the service was rated as 'inadequate' overall, and was placed in 'Special Measures'. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe.

This inspection was conducted over two days. The first day of the inspection was unannounced and carried out by two adult social care inspectors. The second day of the inspection was announced and undertaken by an inspector for adult social care, an expert by experience and a pharmacist. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Before the inspection we reviewed information we held about the service. This included monthly reports we had asked the provider to send to us detailing the action they had taken and were taking following the last inspection. We also reviewed notifications sent to us by the provider. A notification is information about important events, which the service is required to send us by law.

During the inspection we spoke with 15 people who lived at Waterloo House and six members of staff. We also spoke with the local authority (Plymouth City Council).

We looked at a sample of records relating to people's needs. This included care three records of people receiving care, such as support plans, risk assessments and daily monitoring records. During our inspection, we looked at the systems in place for managing medicines. We spoke to staff involved in the governance andadministration of medicines, observed medicine administration for five people and looked at 13 medicines administration records (MARs) and a further three people's medicine care plans.

We looked around the premises and observed how staff interacted and supported people. In addition to


records relating to people's care we also viewed other records relating to the running of the service, including training records, quality audits, incident forms, policies and staff files.


Is the service safe?

Our findings At the last inspection in October 2016, we found significant concerns in relation to people's safety. In some cases people did not have assessments and guidelines in place to mitigate risks associated with their care. Staff and management had not always acted promptly to address risk and to keep people safe. People were not always protected from abuse and incidents where people were at risk of harm had not always been reported. People's environment was not safe and staff did not always follow safe infection control procedures. Accident and incident forms were not well completed and care plans and risk assessments werenot updated in a timely way following incidents. The service was rated as inadequate in this area. The provider sent us an action plan telling us how they intended to address these concerns and by when. We also told the provider they must send CQC a monthly report to tell us about their progress in addressing these concerns and improving the quality and safety of services provided to people. At this inspection we found significant improvement in most areas, however, improvement was still required in relation to medicine management and security of the grounds.

At the last inspection, no concerns were found relating to medicine. However, at this inspection we found staff managed medicines in a way that did not always keep people safe. Medicines were checked and recorded when received into the service, and when given to people, on the MAR (Medicine Administration Record). However it was not always possible to check if these were accurate records, as the actual amount of medicines in stock did not match the quantity recorded on the MAR. When we checked the amount of medicines in stock 11 medicines for six people did not match the quantity recorded on the MAR. Staff were unable to explain why this might be.

Some people were prescribed medicines to be taken when required. There was no additional information in place to guide staff about when these medicines might be needed and how long they should be taken for or how they might require monitoring to ensure they were effective. We saw that staff managed 'when required' medicines for people in different ways. Some people were given a 'when required' medicine on a regular basis; other people were asked during the medicines round if a 'when required' medicine was needed; and some were not asked or offered their medicine. Staff told us that some people were given 'when required' medicines regularly. Staff did not record the outcome of giving 'when required' medicines, so could not always be sure that they were effective.

Some people administered some of their own medicines. Although it was recorded on MARs that these medicines were self-administered, there were no risk assessments in place to make sure that people were safe to do so and could use the medicines in a way that meant they would be effective, for example inhalers. This meant that people might not have been getting the full benefit from some of their medicines.

There were two sets of guidance in the medicines policy folder. One set was due for review 18 months beforethe inspection, in January 2016 and had not been updated; the other referred to people living in their own homes rather than a residential service. This policy was not specific to the service and did not tell staff how medicines should be managed in this service. Staff told us they had not seen a medicines policy. There were no audits in place to make sure that medicines systems and processes were robust and to drive quality

Requires Improvement


improvement. Although there were arrangements for safe disposal of unwanted medicines, we saw that some pain relieving patches (that had not been needed for one person since December 2016) had not been disposed of and were still stored in the cupboard. This person had been prescribed a lower strength patch and both strengths were stored together. Not disposing of the higher strength patch increased the risk that the wrong strength patch could be applied.

Not all aspects of medicine management were safe. This was a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. - Safe care and treatment.

Keys to access medicines storage areas were held by the lead carer or team leader. Staff recorded when theywere handed over at shift changes. Medicines requiring cold storage were monitored to check that temperatures were suitable for storing medicines, so that they would be safe and effective. Medicines with potential for misuse, requiring special storage and closer monitoring, were stored and recorded in line with legislation.

Medicines were given by trained staff but they were not checked to make sure they were competent. We observed medicines being administered. The carer took time to engage with people and encouraged them to take their medicines. Medicines were signed for after they were given, although we saw one gap on a MAR where it was not possible to tell if the medicine had been given.

People were encouraged to ask for additional information about their medicines. We were told about one person who wanted to stop taking a medicine because of the side effects they were experiencing. This person talked to staff and their GP about the risks of stopping this medicine and the benefits of continuing to take it. This allowed them to make a balanced decision about whether to continue or not.

People told us, "Yes staff ensure we take it and enter it on the MAR charts"; "I know exactly what my medication is for and staff give it to me when needed" and "They help me with my medication and I know exactly what it's for. I am diabetic so need to be careful about what I eat etc; I like to get up for 8.30am so I can have my insulin."

The consultancy team were proactive in addressing these medicine issues immediately undertaking an internal audit, sourcing specialist advice and arranging in house training on best practice in this area. A specialist advisor in medicine management had been booked to review the medicine processes in July 2017.Further external training was being arranged for staff leading on medicines within the service.

We checked the external and internal environment to ensure the provider had taken action to keep people safe. We found improvements had been made within the service. Anti-ligature chords were in place where required, radiator covers had been fitted to prevent scalding and equipment was kept behind locked doors. However, the garden shed which contained maintenance equipment and tools such as a saw and white spirit was unlocked and accessible to people. We also found general waste for example a large pile of wood with sharp nails had not been removed. These items may have posed a risk to people or others.

Not assessing the risks to the health and safety of service users and doing all that is reasonably practicable to mitigate such risks to keep people safe is a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We spoke with the provider during the inspection and the maintenance man made the external environmentsafe during the inspection.


People were supported by sufficient staff to keep them safe and meet their care and support needs. There were four care staff, a cook, a cleaner, plus members of the improvement team on duty in the home on the first day of the inspection. There were 15 people living there (plus two in hospital). New staff had recently been recruited and the use of agency staff had reduced. Where agency staff were used, they requested staff that were familiar to the home to ensure continuity of care for people. Staffing levels at the week end had also improved to enable people to engage in activities throughout the week. People and staff commented, "Ithink there is although we could do with more at night"; "I think we definitely have enough staff. If needed we do have agency staff and they seem to like it here in fact two or three have asked to be considered for any permanent posts here"; "Could do with more staff to see to things so we don't have to work!" Staff commented, "I think there is enough staff here, I haven't been here long but it is the friendliest home I have worked in, you are not rushed and have time to sit and talk to residents"; "Most of the time we have enough staff but occasionally due to sickness there might be a blip. The consultants have increased staffing levels" and "They only have one driver at the moment but they are training another."

Staff recruitment checks were undertaken prior to new staff starting at the service to ensure they were safe to work with vulnerable people. New employees completed an application form, were interviewed and two references were checked. All staff files we reviewed had a Disclosure and Barring check (DBS).

People were protected by safe infection control practices. Steps had been taken to address the concerns we had found at the last inspection. All areas were of Waterloo house were clean. A cleaning person was employed who took a pride in their job.

Most bathrooms and toilets were clean, well maintained, bright, modern and in good order. There were paper towel dispensers, soap dispensers, alcohol hand gel dispensers in every toilet and bathroom. Around the home there were disposable aprons and gloves of all sizes readily available. There were also many bottles of alcohol hand sanitizer around the home, including the entrance hall. There were systems in place to ensure that any wet towels left in bathrooms were removed promptly and washed. Staff checked bathrooms and toilets throughout the day to ensure they were always clean.

The laundry was tidy, with just a very small amount of washing in a basket waiting to be washed. Clean washing was neatly folded on shelving ready for people to collect. We saw the cleaning person returning some clothing to one person, hanging it neatly in their wardrobe. The laundry floor was tiled for easy cleaning. There were two washing machines – one large industrial size and one smaller domestic size. The smaller machine had been out of order for many months and staff were unsure if or when it would be repaired or replaced. People living in the home were encouraged to do their own washing. Replacement of the smaller machine would support them to do this.

Infection control policies were in place but these were out of date and were about to be reviewed and updated. They did not adequately cover the NICE (best practice) guidance. For example, there was no guidance on laundry procedures for soiled linen, cleaning of commodes, curtains or mattresses. Regular infection control audits were carried out using Plymouth City Council checklists but areas specific to the service needed to be added to the checklist. There were no infection control risk assessments in place. Staff had received some training on infection control during their induction but this covered the basic principles only, and had been included on more general Health and Safety training. The quality and content of the training had not been checked. The consultancy team had monitored infection control practice and had given staff advice on good practice during their monitoring checks of the building since they started in November 2017. Good practice had also been reinforced during staff meetings and handovers. People living in the home had also been reminded of the need to follow safe practice when they used the kitchen, for example by using gloves and aprons.


Procedures for dealing with incontinence pads and soiled laundry were not entirely safe. Staff had been instructed to use red disposable sacks for soiled laundry. However, they had not received instructions on safe temperatures to wash the laundry. There were no laundry trolleys which meant there was a risk soiled or dirty laundry may be placed on the floor. The process for soiled pads needed clarification in the service's policy. We were told these were placed in clear bags and then in yellow bags. The consultancy team agreed to review infection control procedures in line with best practice guidance following the inspection.

Safe procedures had been put in place when a person developed an infection that placed other people in the home at risk. Sharps bins were in place for needles and the consultancy team had arranged a contract for the safe removal and receipt of sharps bins.

The kitchen was clean and well organised and had been rated as 5 star (Good) by the Environmental Health department.

We recommend that the service consider current guidance on infection control and prevention and update their policies and practice accordingly.

We reviewed accident and incident forms since the previous inspection and found these were much better. The improvement team were supporting staff to reflect on incidents which had occurred and checking action had been taken where required following any event within the service.

Risk assessments had been put in place and updated following the last inspection. Risk assessments were specific to people's particular needs in relation to their mental health for example if people were at risk of self-neglect, self-harm, had poor traffic awareness or were a fire risk due to their smoking habits. The consultancy team had plans to improve people's physical risk assessments in relation to their skin needs and nutritional needs (MUST and Waterlow Assessments). This would be important as people at the service were ageing and some had physical health needs.

The risk assessments for some people stated that they were at risk of displaying behaviours that may put them or others at risk. The risk assessments described these behaviours or provided information on how they could be reduced or managed by staff supporting them. For example, if a person was agitated guidancewas in place for staff to approach in pairs, remain calm and use distraction and de-escalation techniques.

Since the last inspection staff had completed safeguarding training and had been provided with informationabout how to raise concerns and protect people who may be at risk. Minutes of staff meetings confirmed safeguarding was regularly discussed as an agenda item. Most people we spoke with told us they felt safe. Staff had received training and knew how to protect people from the risk of abuse and the provider was awaiting further training dates to update all staff. A member of staff talked about the importance of protecting people from abuse and said "I wouldn't hesitate (to report any incident of abuse)."

People told us they felt safe living at the service. Comments from people included "I have never felt so safe prior to living here. The staff are absolutely brilliant and we are one big happy family. When new residents arrive we befriend them especially as some are a bit afraid to talk to people. For example (X) was very quiet when he arrived so when he was sat out in the garden I went out and talked to him and told him he was nowpart of our family and we would help him settle in. He is now really funny, he is brilliant and we all love him"; "I have not felt unsafe recently"; "I feel lovely and safe here but a policeman came with me the other day to tell them I was not being safe. I like to walk up to the village but I walk in the road as the curbs are high and I have trouble with steep curbs and steps. They have told me I must not walk in the road"; "I am a DOL's resident do you know what that means? It means I can't go out on my own. I get frustrated but know I am


safe here and they help me manage my behaviour as much as they can" and "Everyone is nice here there is no need for anyone to fill unsafe or to be afraid of any of anyone."

People also told us if they were worried or concerned they would feel confident talking to staff at Waterloo House, "I can talk to any of the staff if I am worried or upset. I particularly like (X) heading up the consultants,I hit it off with her right away and she would be the first person I would talk to if she was around"; "There are two members of staff I can talk to and they help me sort things out"; "I can talk to all staff. I don't have much to do with other residents but I do like living here" and "Staff are ace here. You can talk to them they help mework through my worries."


Is the service effective?

Our findings At the last inspection on the 12 and 25 October and 1 November 2016, we found concerns relating to the monitoring and management of people's healthcare needs. We also found concerns related to staff training,particularly around staff knowledge of mental health and drug and alcohol dependency. We also found a lack of Mental Capacity Act assessments in place to guide specific decisions related to people's care and best interest processes were not being followed in line with the Mental Capacity Act. The provider sent us an action plan telling us how they intended to address these concerns and by when. We also asked the providerto send us a monthly report to tell us about their progress in addressing the concerns we had found. At this inspection we found improvements had been made in the management and monitoring of people's healthcare needs. However, further staff training was required in some areas including the Mental Capacity Act and in mental health and substance misuse.

We checked whether the service was working within the principles of the Mental Capacity Act 2005 (MCA) and whether any conditions or authorisations to deprive a person of their liberty were being managed appropriately. The MCA provides a legal framework for making decisions on behalf of people who may lack the mental capacity to do so for themselves. The act requires as far as possible people make their own decisions and are helped to do so when needed. When a person lacks the mental capacity to make particular decisions, any made on their behalf must be in their best interests and be least restrictive.

Not all staff had undertaken training in the Mental Capacity Act and some staff found it difficult to explain how this law protected people's human rights. Capacity assessments were completed for people in relation to different aspects of their care and these had been documented and reviewed as part of the care plan review process. Staff were aware of when people's capacity to make decisions could fluctuate but less confident explaining when they needed to consider best interest discussions. Staff were being guided and supported to understand these processes with support from the consultancy team whilst further training was arranged. Care records also included consent forms in relation to people moving into the home, use of social media, and access to individual's records. We observed staff asking for people's consent before providing care and treatment and using their knowledge of individuals to assess if people were happy with the care being provided. We were not confident staff understood some practices such as turning the television off at a certain time could be seen as restrictive (staff were doing this to support people to rest at night and encourage a good sleep pattern) and clearer documentation was required if people did not have the capacity to agree to these "house rules".

People can only be deprived of their liberty in order to receive care and treatment, which is in their best interests and legally authorised under the MCA. The authorisation procedure for this in care homes is called the Deprivation of Liberty Safeguards. Deprivation of Liberty Safeguards (DoLS) authorisations were in place for two people at the service. Other people had restrictions in place due to their mental health needs. The service was aware of the restrictions in place on people and ensured the principles of the Mental Capacity Act were followed and people's human and legal rights protected.

We recommend the service sources Mental Capacity Act training for staff and reviews their policies and

Requires Improvement


procedures in line with the Mental Capacity Act Code of Practice.

People said their health needs were met by the service and staff supporting them. Comments included, "I get a lot of pain when walking but they are trying to help me do a bit more exercise. They took me to the GP who said I have to exercise more but it is difficult when you're in pain"; "They take me to the chiropodist"; "I smoke too much and I have tried to give up with the help of the staff. I have tried the gum and patches but it hasn't worked" and "If I am having difficulty with my diabetes I go to the staff who will help me. They normally take me to the GP. Once a year the opticians come to the home and check our sight and we also goto the dental access centre."

Care records in most cases provided staff with good detail about people's healthcare needs and staff were becoming familiar with this information. Visiting healthcare professionals were encouraged to write up visits in people's care records to improve communication and to aid staff to follow professional guidance.

People's health needs were identified and addressed promptly. The health of each person was discussed at handover meetings, and any concerns, appointments, and particular monitoring arrangements were discussed and shared between the staff on duty and person in charge.

Since the previous inspection the provider and consultancy team had reviewed the training needs of staff. Staff had received training in activity planning and care planning, medicine training, safeguarding training, nutrition and diabetes training, first aid training and training in managing behaviour which staff could find challenging. Some staff had undertaken first aid training and further dates were being organised. Manual handling training, infection control training and mental capacity act training dates were being arranged. Conflict resolution and breakaway training had also been requested by the consultancy team but staff had not yet received this. This training would support staff to develop skills diffusing and deescalating situations and teach them how to safely remove themselves from a person if they were grabbed. Staff were learning and being guided to develop skills in managing people's complex mental health needs from the consultancyteam. Following the inspection we spoke with the consultancy service in the absence of the provider (due to ill health) to provide some formal training in the specific areas identified during the last inspection, personality disorders and substance use. This would support staff to understand and feel more confident supporting people with these needs. This was arranged promptly.

Staff told us, "I feel we are trained well to meet the resident's needs. I have under taken training in Safeguarding, Mental Health, Autism, Medication. I have a little knowledge of the Mental Capacity Act (MCA) as I think we have five residents who may have issues under MCA. I have not received MCA training or DoLs Training although I believe two of our residents are under the DOLs provision. If I feel I really need to go on a training course I know I can apply and the management will look into it. If they think it suitable they can grant funding for it"; "I am very new here and have had the following training: Safeguarding, moving and handling and first aid. I have a care certificate from a previous job but I have not had any MCA or DoLs training as yet"; "Even though I just do the cleaning here I have received training to ensure I am safe and ableto do the job appropriately" and "Most of mine needs topping up although I have just completed a distance learning certificated course on challenging behaviour and I have completed courses on DoLs and MCA. I have also had training on mental health. If I requested more training I am sure they would try and find a course available."

Staff said they felt well supported. New staff told us they had an induction which met their needs and the consultancy team and colleagues were on hand to advise and answered any questions, "Any questions at allI can ask, they are fantastic"; "I have received a lot support since starting work here. I am shadowing others and have learnt a lot about the residents and their needs including those with challenging behaviour and


how to deal with this behaviour."

Staff were supported through informal supervision and more formal one to one supervision had started. Staff had been kept up to date with changes since the previous inspection and felt comfortable approachingthe consultancy team if they needed guidance or support. Appraisals were not yet in place but were plannedas part of improvement in this area. Staff shared with us, "Since the consultants have been here they have improved conditions in a big way not only are the residents happier but I feel a lot more supported. They areapproachable all of the time and check out with us how things are going"; "We have weekly staff meetings where we discuss our concerns. We have good peer support and we work as a team. Although I am a team leader there is little hierarchy everyone does their best on an equal level."

People's need for a balanced diet and to be hydrated was met. People had a range of needs in relation to mealtimes and diet. Some people were able to eat independently and chose where they wanted to eat their meals. A new chef had been employed since the previous inspection and they had met with the people livingat Waterloo house to ask for their menu ideas. People had said they'd like toad in the hole, stew and dumplings, rice pudding and these had been added to the menu. Stew and dumplings were planned for the inspection day but due to a heat wave, people had agreed to a lighter meal choice.

Staff told us there was a good budget allowed for catering and a food shop was regularly delivered with petty cash available to support smaller purchases or ad hoc picnic events. People were able to access the kitchen with staff support. There was usually hot water available in the dining room for people to access hot drink making facilities but the hot water tank was broken and awaiting replacement. There were ample cold drinks available in the lounge and people freely helped themselves to these.

Staff were aware of those who required particular support with eating either due to their mental health needs or physical needs and we saw this reflected in people's care records and observed staff providing the support people needed. People's weights were closely monitored and people given advice about healthy eating and weight management where appropriate. Some people at the home attended an interactive nutritional talk on the second day of the inspection asking the trainer questions about their diabetes or other questions they had relating to their diet.

Staff told us, "We are aware of all residents like and dislikes. There are always plenty of drinks available and they will ask for snacks and cold drinks. Most residents make their own hot drinks in the kitchen. We do encourage the diabetics to eat sensibly in order to balance their insulin more effectively. There is always plenty of fruit available."

People were very positive about the food available at the home telling us, "You can ask for a cold drink if none around. I make my own cups of tea"; "Meals here are very nice and there is always plenty to eat and drink"; "There is always plenty to drink and various snacks such as crisps. Lots of fruit available like bananas and apples"; "Residents do have access to drinks and most are able to make their own hot drinks. There are snacks and fresh fruit available all of the time"; "The food here is lovely and today the Team Leader is cooking lunch. He is an excellent cook and we love his meals. There are choices and they also provide options for the vegetarians, you can choose that even if not a vegetarian"; "The meals are lovely here and you get plenty to drink. We have nice picnics too and when we go out we get a cup of tea and an ice-cream"; "The meals here are very nice and we get lots of choice. Once a month we have a meeting to decide the menu. Monday's fry up is to die for" and "We have lovely meals here. I don't like red meats but I do like chicken. I had the vegetarian dish today it was really nice. I have to be careful about what I eat being diabetic."


Is the service caring?

Our findings At the last inspection on the 12 and 25 October and 1 November 2017 we found aspects of the service were not always caring. Staff had struggled with some of the new admissions at the time of the last inspection without the guidance and support of a manager. Information about how to support people was lacking and some people at the home were not happy and felt their quality of life had been reduced. The provider sent us an action plan telling us how they intended to address these concerns and by when. We also asked the provider to send us a monthly report to tell us about their progress in addressing the concerns we had found. At this inspection we found improvements had been made.

People told us their privacy and dignity was promoted and respected. Staff told us they always knocked on people's doors before entering their rooms and addressed people in the manner they preferred. Staff knew which people at the home enjoyed a laugh and a joke with them and those where they needed to have a more formal conversation. Some staff had worked at the home for many years (over 15 years) so they knew people well and the small things which made them feel they mattered. Staff told us, "I feel privacy and dignity is very important especially when undertaking personal care. I always ensure the toilet and bathroom doors are shut when residents are using them. Residents are able to lock their own rooms. I never enter a room without knocking and being asked to come in. If I don't get an answer I might check on anotherresident and try again. If I still don't get a response I have a pass key and will enter the room to make sure all is well."

People commented, "They don't just walk into your room, they always knock first. If you're upset they try and help you get over it"; "Staff are kind and I have a good rapport with them. You can have a laugh and jokewith them. They do respect me and my dignity when helping me wash or shower they make sure the doors are shut and I have plenty of towels. I fell and injured my knee, it is still bruised, I am frightened I will fall again so now the carer stays with me"; "The staff are really kind to me, they help me wash and dress and treat me with dignity and respect. I could be more independent but staff don't force me to do more." "I like it here and get on well with everyone."

"The staff here are good. I don't lock my room but they always knock the door before coming in. I do feel remorseful after I have 'kicked off'. I get so frustrated but they do support me and calm me down. I am lucky that all the carers here help me but two in particular are really good with me. One of them lives beside the home and has a lovely dog which she lets me pet and fuss over. I want to mention the cleaning lady too as she is really lovely and dedicated to her job. She has got me a lot more house trained as my room was a mess but now I keep it tidy as she is so good at keeping it clean as well as the rest of the home" and "I get on well with all the staff. They respect your privacy but are always willing to help they help me put my socks on as I can't reach my feet."

People told us the care at Waterloo House met their needs. "It does meet my needs. I could do a bit more than I do already such as my own washing and ironing, I don't mind doing my washing occasionally but I don't do my ironing. I was offered a chance to move to a new place but I love it here and this is my family so Itold them I don't want to move they are happy with that"; "My needs are met here and I love living here. I am

Good


very happy here although I don't have anyone to visit me. I could do with a girlfriend"; "The care is excellent. We are so lucky and they help you work through your difficult times without falling out with you. When I havebeen frustrated and 'kicked off' they don't hold it against you. I am always very sorry afterwards as I know they do their best for me"; "It is okay here and I can talk to staff. They offered me a move to two different places but you had to do your own meals and I just don't feel up to it so had to stay here. Occasionally I think I might like to go elsewhere."

People told us they could talk to staff and felt listened to, "Yes they listen"; "They will listen to you"; "All the staff take time to sit with you and talk to you and yes they do listen to us. We have monthly meetings as well where we can raise issues. The owner comes and we have asked him for different things which he will supplyif appropriate. He has told us he is getting us some new furniture."

People's relatives and friends could visit when they wanted. People shared, "I have four sons and they do visit sometimes. I look forward to them coming but they don't come very often. The other residents are like my family now and we all support one another"; "My sister comes to see me every two weeks"; "I see my brother quite often, sometimes he goes to town with me but if I am not going to town he will get my ciggy's and tobacco for me"; "My family call and see me occasionally and they take me out"; "I visit my Mum every Thursday."

People complimentary about the care provided by staff and staff spoke about people with compassion and kindness. The home had a friendly warm atmosphere. People living at Waterloo house described it as a largefamily. We heard some lovely, friendly conversation between people and between staff and people. They talked about different activities and what things they had enjoying such as picnics and trips to the garden centre.

Other agencies were positive about how caring the staff were in the home.

Staff readily provided information for people, telling them what was happening and why. We saw letters to people following the last inspection explaining to them the outcome of the inspection and what would happen. This included telling people about visitors in the home as well as plans for the day such as the meal and activities. Information about what was happening in the home and future events were visible on noticeboards.


Is the service responsive?

Our findings At the last inspection on the 12 and 25 October and 1 November 2016, we found concerns relating to the planning of people's care. Care records were not personalised and did not provide staff with sufficient information to respond effectively and consistently to people's needs. We were also concerned that some people newly admitted to the home had not been assessed thoroughly to ensure the service was the correct placement for their needs. We asked the provider to send us the service's pre-admission policy and procedure by 1st February 2017. This was received in May 2017. We also found limited activities were available and these did not always reflect people's particular wishes or interests. The provider sent us an action plan telling us how they intended to address these concerns and by when. We also asked the providerto send us a monthly report to tell us about their progress in addressing the concerns we had found.

The consultancy team told us that following the last inspection reviews had been completed of the care arrangements for all people living in the service. The consultancy team advised, those people who had wanted to be involved in care reviews were, and their support plans had been updated. An audit had also been carried out of people's care plans to ensure they contained up to date information.

We looked at a sample of care records. This information included some background information and important contacts such as relatives and other agencies involved in their care. People's individual records also included a plan of care. Care plans are a tool used to inform and direct staff about people's health and social care needs. Our inspection in October and November 2016, found people's care plans did not ensure they received person centred care. At this inspection we found improvements had been made. For example, there was a person in pain due to their health needs and they had a personalised plan in place how to support them to reduce their pain through regular exercise. Staff were following people's support plans so people received consistent care.

Staff we spoke with knew more about people and their histories and backgrounds than at the previous inspection. This supported them to understand people and provide individualised care. Staff told us about people and this matched what we read in people's care records.

Great improvement had been made with activities. Resident meetings were held regularly and people living in the home discussed what they would like to do and external trips. A new activities board was in place so people were aware of what was going on. We were told about a "world event" coffee morning, trips to the local parks, picnics, bbq's, bingo and relaxation and pamper mornings. People felt involved in deciding whatto do and were thoroughly enjoying the outings. People commented, "I can go out if I wish and they do take us out on trips. There are all sorts of activities on offer. I like the pamper day as I get my nails and hair done. We can join in craft classes and there is always something going on"; "I don't do a lot but they do get in somenice DVD's"; "I like football and go to watch Argyle on a Saturday. I also go their away games as it gets me outfor the day. This year a member of staff helped to get a season ticket saving me quite a lot of money over theyear". Staff shared, "We have a lot of activities now for residents. We take residents out on trips. Recently we have been to a garden centres as we had some money to buy plants for the garden, the residents enjoyed having a drink in the café. We have also been on picnics to Mount Edgecombe and Mount Batten"; "We do a

Good


lot with residents and encourage them to use their time constructively. We take them out and about especially when the weather is good."

People's rooms were personalised to their liking and reflected their hobbies and personal tastes. People were dressed as they chose and had their hair, jewellery and make up as they wanted. One person commented, "I like being able to choose for myself how I decorate my bedroom including having duvet covers and curtains that I like."

People felt comfortable raising concerns. People told us, "I would always go to (name given) if I wanted to make a complaint. She listens and helps you resolve it. Not all managers before were as easy to speak too"; "I did complain but can't remember the details now but it was resolved"; "I would not know how to make a complaint. I would talk to the consultant manager she is very good if I was unhappy about anything"; "I don't really think I do but if there is anything wrong I go to the consultants. If I am worried or upset staff come to me quickly" and "I have not ever had to make a complaint but would know how to make one if necessary."

We reviewed the complaints file and the one complaint which had been made. The provider had partially addressed this complaint following the provider's policy. The complaint included concerns about the poor access for wheelchairs which we were unable to see had been addressed. During feedback we spoke with the provider about looking to improve wheelchair access and ensuring all aspects of people's complaints were addressed fully and used to drive learning within the service. At the time of the inspection no one was using a wheelchair.


Is the service well-led?

Our findings At the last inspection on the 12 and 25 October and 1 November 2016 we found the service was not well-led. The rating for this area was found to be inadequate. There was no registered manager in post. The provider did not have an effective system in place to monitor the quality of care people received. Staff said they did not feel supported or able to raise concerns, which they said had resulted in low morale and a negative impact on people who received care.

In line with our enforcement policy we made the decision to place conditions on the provider's registration. These are that the registered person must carry out a monthly audit of infection control procedures, and of all care plans and risk assessments for all service users and send to the Care Quality Commission a monthly report which states the action taken or to be taken as a result of these audits. Also, that the registered person must review the service's pre-admission policy and procedure and send it to the Care Quality Commission. The policy and procedure for new admissions to the service must be reviewed as needed and any updates or changes must be forwarded to the Commission as they are made. And the registered provider must send to the Care Quality Commission a progress report on the action plan dated 12 December2016 and thereafter such reports must be sent to the Commission on the first of each month, commencing 01 February 2017.

The provider sent us an action plan telling us how they intended to address these concerns and by when. We have received regular reports and the admission policy and procedure has been reviewed.

At this inspection, despite the provider trying to actively recruit there was still no registered manager in post.A consultancy team had been brought in by the provider to address the concerns from the last inspection and provide leadership and guidance to staff. The consultancy team were commissioned for project work and did not have full operational oversight. Although there had been good improvement in many areas during this inspection, we found further improvements were still needed to ensure the on-going quality and safety of the service. Without a permanent manager in post, it was too early to judge if these improvements would be sustained.

The consultancy team were supported by the provider, a deputy manager and a team leader but their roles and responsibilities in relation to quality monitoring were not clear. We were told that following the last inspection in October 2016 a number of audits were carried out with a particular focus on areas of concern such as, care plans, infection control and risk assessments. These, alongside the last report had enabled the consultancy team to develop an action plan to drive improvements within the service.

Staff told us the provider was more involved in the service than previously. They were visiting more regularly and had met with staff and the people at the service. The provider had frequent contact with the consultancy team who fedback to him regularly, at times, on a daily basis. However, the providers own governance framework was not clear. We were told and found that some issues had been raised with the provider but there was sometimes a delay in action being agreed and taken, for example the downstairs shower which required repair and the external environmental risks we found.

Inadequate


We also found there was no oversight from the provider regarding the medicines management plans and some staff training needs remained unmet for example the Mental Capacity Act training. Although the consultants were at the service every day to guide and support staff, staff needed these skills and competencies within their own team. The provider had also failed to complete a Provider Information Return (PIR) when requested by the Commission or delegate this to the consultancy team. Dates and information requested by the Commission with regard to the positive conditions which had been set had missed the deadline by several months. The provider's policies also needed reviewing to reflect procedures at Waterloo house, best practice, and current regulations. Many policies we reviewed were out of date, for example the medicines policy and infection control policy. These did not provide sufficient, up to date instructions on good practice. This meant in the absence of the consultancy team, staff would not have guidance on current safe procedures to be followed. We were told policies were in the process of being reviewed to reflect best practice.

The governance arrangements in place had not ensured full compliance with the regulations which placed people at risk of receiving unsafe and poor quality care. This is a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People told us they had confidence in the interim management arrangements and felt the service had improved but they were concerned that it was not a permanent arrangement. Comments included, "It is better now but hasn't always been like this. Things have improved with the consultants and hopefully it will stay as good when we get a new manager"; "It is better now that the consultants have been here and made improvements. Residents and staff are much happier and we feel we get a lot more support"; "The consultants have done really well. They are so good. This place can't retain managers. We have to keep learning new names"; "We have not had good managers in the past"; "I have not been here long and therefore don't know what went on here before the consultants arrived. I understand from other staff they have made big improvements to the service and support of the residents and staff. I think they show excellent leadership and would hope this is continued when a new manager takes over" and "I love the staff but I am very worried about what will happen when the consultants leave. I have built a great rapport with them; one in particular gives me inspiration. I would like to do a parachute jump!" and "In the past we have had some poor choices of managers. The consultants have increased staff levels and conditions have improved. We need a manager who can carry on with this high level of support but currently retention and recruitment appears difficult."

People living at the service were asked for their views, whether they were happy and whether they had any suggestions for improvements. People shared with the inspection team, "They do ask and we get residents meetings every month where we can bring up things. The owner attends and he is thinking of getting us some new settees for the lounge. It would be a good idea as I struggle to get out of the current ones"; "Yes they do and they listen to what you say"; "They do ask and I am very happy here"; "I am lucky to be living here as I get on well with everyone"; "We have monthly meetings with residents where they can raise issues and choose the following four week menu. Some residents are louder than others so I do try and encourage the quieter ones to have their say"; "Yes they do and we have monthly resident meetings which I try to go to. The owner comes and we asked for a Hi-Fi and he got one. He is also getting us some new furniture. We can have our say at these meetings. I really like it here."

Staff felt supported and able to approach the consultancy team for advice. They felt confident raising concerns and felt these would be actioned. Staff felt listened to and valued. Regular staff meetings were held, which allowed staff time to share experiences and reflect on practices. It also provided a forum for the consultancy team to share information and raise any particular issues or concerns about the service. We sawminutes of recent staff meetings and attended one during the inspection. Staff meetings were held weekly


and demonstrated a wide range of topics were discussed including safeguarding, inspections and staff roles and responsibilities.

Statutory notifications which tell us about specific events at the service had been submitted as required and in a timely way.

The provider and consultancy team had worked alongside the local authority to address the failings found at the last inspection. Feedback about the changes made to date were positive.

Following the last inspection the provider had written to people and relatives about the findings of the inspection and the action they would be taking to address the issues found. They had apologised to people about the failings and kept them updated of progress and improvements. This reflected the requirements of the Duty of Candour. The Duty of Candour is a legal obligation to act in an open and transparent way in relation to care and treatment and puts a responsibility on providers to promote the ethos of honesty, to learn from mistakes and admit when things have gone wrong.

At the end of the inspection we provided short feedback of what we had found. Shortly after the inspection the service undertook a full medicines audit and made plans to provide some in house training on substance misuse. This would be asked for by CQC as part of the inspection process; however, the consultancy service and provider's promptness further demonstrated their willingness and determination toimprove the services provided to people living at Waterloo House.


The table below shows where regulations were not being met and we have asked the provider to send us a report that says what action they are going to take.We will check that this action is taken by the provider.

Regulated activity RegulationAccommodation for persons who require nursing or personal care

Regulation 12 HSCA RA Regulations 2014 Safe care and treatment

Safe Care and Treatment

The management of medicines was not always safe.

The external environment posed a risk to the health and safety of service users receiving careand treatment.

This is a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) 2014.

Regulated activity RegulationAccommodation for persons who require nursing or personal care

Regulation 17 HSCA RA Regulations 2014 Good governance

Good Governance

The governance systems and processes in placemust be robust to assess, monitor and improve the quality of services and mitigate potential risks.

This is a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Action we have told the provider to take

This section is primarily information for the provider

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